Staining and Other Adjunctive Methods to Assist with Placing

48 Staining and Other Adjunctive Methods to Assist with Placing

David Josephitis

Summary

Staining and other adjunctive methods add to the precision and efficiency in hair transplantation. Staining the incision sites with gentian violet or methylene blue gives the surgical team added advantages that make for a more successful procedure. Shaving the scalp preoperatively may make for a more effective case. Other techniques such as using marking pens, diagrams, and different types of incision (i.e., sagittal, coronal), aid the surgical staff in proper placement of grafts. Finally, logistics plays a part in efficient time management.

Keywords: stain methylene blue gentian violet shaving sagittal coronal logistics

Key Points

•Staining enhances the creation of sites and eases the placement of grafts.

•Demarcating zones in the recipient area gives the surgeon added control.

•Communication between the surgeon and staff is key to an efficient and effective surgery.

48.1 Introduction

The entire hair transplant procedure can be viewed as a series of individual steps with the ultimate goal being the timely and successful placement of grafts. Other steps include donor excision with follicular unit excision (FUE) or strip and creation of recipient sites Modifications to the surgery, such as making of extralarge recipient sites for larger grafts or adding additional anesthesia (i.e., nerve blocks) for those with a greater need for pain control, are individually tailored for the patient. Finally, there are those techniques that can be employed purely for the sake of improving the quality of care and for easing the task at hand for both the surgeon and the staff. Staining and other adjunctive methods to assist in placing are just those types of techniques. Physicians who use them appropriately will find that with only a little extra effort the procedure can be enhanced and potentially a better result can be produced.

48.2 Staining the Skin Surface

The use of a stain may facilitate the creation of sites by the physician, speed up the placement of grafts by the staff, and ensure correct insertion of grafts. The two most common stains used are gentian violet and methylene blue. Gentian violet was originally developed for use as a histological stain and was also found to have use as an early topical antiseptic with antibacterial and antifungal properties. It stains the skin a dark purple, and nonmedically it has been used for coloring of consumer products such as paper. Methylene blue has also been used for many years as a treatment for various medical issues such as carbon monoxide poisoning, hypotension, and even for the treatment of malaria. When applied, it leaves a dark greenish-blue color on the skin (Fig. 48.1). Mouse studies indicate that the use of gentian violet may be carcinogenic to certain organs.¹ While there have been no studies performed comparing the risk of these effects on the yield of hair or the potential harmful effects in humans, some transplant physicians prefer to use methylene blue to avoid any additional risks.

Fig. 48.1 Methylene blue and gentian violet side by side.

The method of applying stain is simple and is the same with the use of any type of stain. After a number of incisions have been made, the area should be cleaned of blood and dried of any residual liquid or debris. The stain is then “painted” on the recipient area with a clean gauze or cotton-tipped applicator. When applying, it is helpful to do so with strokes perpendicular to the direction of the incisions, as this tends to color them more completely. Wipe off any excess stain with more gauze and apply alcohol hand gel and/or alcohol pads to the area to remove any excess color from the scalp. Finally, wash the scalp thoroughly with saline to remove any alcohol or residue.

Staining can be employed for a number of reasons during the procedure. Occasionally, there can be some difficulty for the surgeon in visualizing the incision sites while they are being made. This may be due to a darker skin complexion or an absence of contrast between the incision sites and paler skin tones. Even with high magnification, it is sometimes challenging to see where openings were made in the skin without stretching the skin perpendicular to the direction of the incision or “feeling” for the incisions using forceps as a probe. In these cases, it might be helpful to stain the skin a number of times throughout the creation of sites in order to reduce gaps devoid of sites and also to minimize reinjuring a site that has already been made (Fig. 48.2).²^,³

Fig. 48.2 (a, b) Comparison of stained and nonstained sites.

Some physicians find it helpful to make FUE sites on the day prior to doing the actual extractions and placement of grafts. The second day can be focused on extracting and placing, and the time out of body for the grafts is minimized. The next day, the sites have not closed up and are quite readily reopened. A potential difficulty with premade sites is that they may be more difficult to see the next day, so staining sites the night before can help prevent this situation.

Others opposed to staining argue that the products used may be toxic to the grafts as discussed earlier. They also consider the potential for a permanent tattooing of the sites with the use of stain. However, there is little reason to believe that only staining the epidermis harms the grafts. The stain is applied to the skin surface prior to any of the grafts being placed, and any excess is thoroughly washed from the surface with saline. Only after the area is cleaned and prepped are the grafts placed in the routine manner. The author and others have been using this method for years and have not encountered any ill effects or poor growth.4 The stain also does not permanently “tattoo” the scalp. Typically, when tattoos are created, the pigment used is placed into the intradermal layer, allowing the color to be “trapped.” The staining used in hair transplantation is applied to the surface and only highlights the epidermis of the scalp.

One word of warning is that the hair transplant surgeon (HRS) must be cautious in using dyes with patients with light-colored hair as the dye will get onto the hair. With dark hair, this is not apparent, but with blond or white hair the patient may leave your surgery with bright blue or green hair. They will not be happy if you send them home like that as the dye does not come out.

48.3 Shaving the Recipient Area

Shaving consists of trimming down all or most of the recipient area so that the long native hair is not obstructing the creation of recipient sites or the transplanting of grafts. However, there is some debate regarding this shaving as it is not actually a necessity and it can disrupt the social life of the patient. Physicians supportive of shaving argue that they can more easily make sites and place the grafts saving time and possibly improving overall yield. With high-powered magnification, any trauma to the existing surrounding hairs can be avoided as the angle of exit can easily be mimicked. The surgery also moves more quickly as the long hair does not have to continually be moved aside during site creation. This also benefits the staff when placing grafts, as hair cannot then become trapped beneath a transplanted graft. Finally, postoperative care is somewhat safer and more convenient as grafts are less likely to become dislodged because grooming is reduced.

The negative aspects of shaving the scalp for surgery are obvious and have everything to do with the patient returning to work and life. It is obviously most disruptive for women, but it is also disruptive for men with significant preexisting hair. Those patients with the ability to take more time off work, wear a hat, or work in a more limited capacity are the best candidates for shaving. The author takes the middle road and shaves those patients who are willing and able to do so within their social constraints and careers. Those who have a very large surgery planned are usually encouraged to allow the shaving of most of the recipient area in order to maximize density. Other patients who cannot allow a shaved look must accept a slightly decreased overall graft number and density (Video 48.1).

48.4 Demarcating Areas of Grafting

The majority of clinics today have technicians place most of the grafts; thus, the physician who makes the incisions and develops the plan for where grafts should be placed needs to convey this information to the staff. This can be done verbally and simply by showing the staff where various sizes and types of grafts should go or physical implements or guides can be used to help direct the staff and make for smooth and efficient graft placement.

One way of delineating various areas of the recipient zone is by the use of a surgical marker (Fig. 48.3). The technician can easily see where one group of grafts should be placed adjacent to another. The use of stain can similarly be used to show various separate regions on the scalp. Another efficient and useful technique is to vary the type of incision for different areas of the recipient area. This can be done in a number of ways. The hairline, for example, can be made with one type of incision (i.e., sagittal or coronal) and the adjacent area(s) can be made with the other type of incision. Still other areas such as the central core or various areas that warrant different grafts can be made with varying types of incisions (Fig. 48.4).⁵ A modification of this technique involves making all of the sites with the preferred method (sagittal or coronal) and only using the alternating method at the borders separating different zones (Fig. 48.5).